Ebook Manual of ambulatory pediatrics (6th edition): Part 2

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PART II

Management
of Common
Pediatric Problems
Elizabeth S. Dunn and Sherri B. St. Pierre

P

art II covers common pediatric health problems within the scope of
practice for nurse practitioners and others responsible for the delivery
of primary health care. The most common management problems are
included and are developed according to the SOAP format, an outline
form that includes subjective data, objective data, assessment, and plan.
The subjective data include the information with which the child or
parent presents or the provider expects to elicit in a history of the presenting illness.
The objective data include the information that would be obtained
from the physical examination of the child and from laboratory tests.
In the assessment, the differential diagnoses for each management
problem are listed and include relevant information to assist the provider
in making an accurate diagnosis. The plan consists of various treatment

modalities used in managing the case, as well as specific pharmaceutical
and symptomatic treatment.
Additionally, for each protocol, there is an extensive education section that includes pertinent information for parents as well as helpful suggestions for the health care provider. It incorporates physical care,
psychosocial issues, medication information, and general information
about the presenting problem.
The etiology, incidence, communicability, and incubation period
have been included for each protocol when applicable. Similarly, complications and indications for follow-up, consultation or referral are a part of
every protocol. Where applicable, resources for both the health care
provider and patient/family have been included at the end of the protocol.
Before initiating a treatment plan for any management problem, several factors must be recognized and assessed. First, a high anxiety level may
interfere with the parent’s or child’s ability to hear and remember the recommended plan; the provider should recognize this anxiety and deal with
it. Second, the ability to follow through with recommendations should be
assessed; for example, a parent already stressed by the daily care of several
small children may find the additional tasks involved in coping with a sick

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child overwhelming. Third, given that compliance is enhanced by knowledge, it is
essential to evaluate the parent’s or child’s understanding of the disease and the treatment. The provider must be aware of potential barriers to compliance, such as ethnic
or religious customs or restrictions, and address them as necessary. Fourth, regarding
pharmaceuticals, it is necessary to ascertain whether the family can afford the prescribed medication, how they intend to measure the dosage, whether they understand
the route of administration, whether they can give it at proper intervals, and whether
they know the importance of continuing the medication for the duration prescribed.
Protocols are included for some of the most common childhood problems.
Changes and additions may need to be noted, because specific practices and geographic locations may necessitate minor revisions. For most effective use, each
protocol should be carefully reviewed by the health care team and amended, if necessary, for their particular health center. Once reviewed and amended by the nurse
practitioner and collaborating physician, they can be used as guidelines for practice
as required for nurses practicing in an expanded role.
Indications for use and dosages for drugs are from current literature. However,
because medicine is a constantly changing science, recommendations for management and standards for use of drugs are subject to frequent change. For this reason,
current recommendations should be reviewed on a regular basis.
Health care providers must be cautious and vigilant in their diagnosis and in
their prescribing of antimicrobials in this era of ever-increasing antibiotic resistance. It is incumbent on us to use antibiotics carefully and judiciously to avoid perpetuating or contributing to the current trend. It is also our responsibility to be aware
of the resistant strains in our communities before prescribing for children.
Anorexia and bulimia have been included in this section. Although these are not
necessarily problems that should be managed solely in the primary health care setting, the health care provider is responsible for the diagnosis, referral, and coordination of care for these contemporary issues. Such cases are presented with pertinent
background information, presenting signs and symptoms, indicators for diagnosis,
broad guidelines for management, and referral sources. The health care provider may
choose to keep a list of local resources pertaining to each of these protocols.
E.S.D.

ACNE
An inflammatory eruption involving the pilosebaceous follicles characterized by
comedones (open and closed), pustules, or cysts. It is a chronic disorder, has a varied presentation, and is often resistant to treatment.
I. Etiology
A. Pilosebaceous follicle activity is stimulated by increased androgen levels during puberty. Desquamation of the follicular wall occurs, creating
a number of cells that, combined with sebum, result in a plug, obstructing the lumen of the follicle. Corynebacterium acne enzymes hydrolyze

these trapped sebaceous lipids, causing distention and rupture of the
sebaceous ducts.


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B. An inflammatory reaction occurs in the dermis with the release of the
keratin, bacteria, and sebum.
II. Incidence
A. Affects approximately 80% of adolescents in varying degrees.
B. Generally disappears by the early 20s in males, somewhat later in
females
C. Severe disease affects males 10 times more frequently than females.
III. Subjective data
A. Vary according to the degree of severity; complaints include:
1. “Bumps,” blackheads, whiteheads, pimples, cysts, scarring
2. Pain on application of pressure
3. Premenstrual flare
B. Location: Face, chest, back, buttocks
C. Pertinent subjective data to obtain

1. Does patient see acne as a problem and want treatment for it?
2. Does acne flare with stress or emotional upheaval?
3. Does acne flare premenstrually?
4. Do seasonal changes affect acne (e.g., improve in summer or
worsen with high humidity)?
5. Does acne worsen in response to certain foods? What are these
types of food?
6. What treatment has been used in the past?
7. What was the response to previous treatment?
8. Has female patient been on birth control pills?
9. Are there any associated endocrine factors?
a. Does patient have regular menstrual periods?
b. Does patient complain of hirsutism?
10. Does patient use cosmetics or creams on skin? Determine type—
oil-based or water-based.
11. Is patient exposed to heavy grease and oil?
D. Note: Often the patient will not complain of any symptoms because of
embarrassment. It is the responsibility of the nurse practitioner to raise
the issue.
IV. Objective data
A. Inspect the entire body. Lesions may be found on the face, earlobes,
scalp, chest, back, buttocks; they generally recur in the same areas.
B. Lesions
1. Mild acne
a. Closed comedones (whiteheads)
b. Open comedones (blackheads)
c. Occasional pustules
2. Moderate acne
a. Comedones—open and closed
b. Papules

c. Pustules


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3. Severe, inflammatory acne
a. Comedones—open and closed
b. Erythematous papules
c. Pustules
d. Cysts
C. Scarring may be present in any stage.
D. Hair is often very oily.
V. Assessment
A. Diagnosis is easily made by the appearance of the different lesions
present on the skin.
B. Assess degree of involvement—both physical and emotional—to determine the best therapeutic plan.
VI. Plan
A. Mild acne
1. Topical bacteriostatic: Benzoyl peroxide products are potent
antimicrobial agents as well as exfoliant, sebostatic, and

comedolytic agent.
a. Use one of the following:
(1) Desquam-X (clear aqueous gel)
(2) Benzagel (clear alcohol gel)
(3) PanOxyl (clear alcohol gel)
(4) Benzac W (2.5% aqueous base gel)
b. Begin with 5% used once daily. (With fair or sensitive skin, use
every other day and increase frequency accordingly.)
c. Follow-up telephone call in 2 weeks. If no sensitivity, gradually increase application to twice daily.
or add
2. Topical antibiotic
a. T-Stat pads, bid
b. Cleocin T lotion, gel, or solution, bid
or
3. Retinoid
a. Retin-A: Use 0.025% cream or 0.01% gel.
or
b. Differin 0.1% gel or cream
(1) Initially, use on a small area every other day, and increase
use to once daily if no irritation develops.
c. Combined retinoid-bacteriostatic therapy
(1) Apply retinoid cream or gel at bedtime
(2) Apply benzoyl peroxide preparation in AM
(3) With Retin-A, do not apply simultaneously; will inactivate both chemicals.
(4) Differin gel or cream has a lower incidence of irritation
than Retin-A gel and is compatible with concurrent application of benzoyl peroxide.


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4. Recheck in the office in 1 month. Continue regimen if condition
responds to treatment. If there is no response to treatment and no
sensitivity to the medication:
a. Increase strength of benzoyl peroxide preparations to 10% used
once daily. Increase frequency to twice daily after 2 weeks if no
sensitivity.
b. Increase strength of Retin-A to 0.05% cream or 0.025% gel
used once daily. Increase frequency to twice daily after 2 weeks
if no sensitivity. Use cream base for dry skin, gel base for
oily skin.
c. During early treatment, an increase in inflammatory lesions is
common. Improvement may take as long as 2 months.
5. Further follow-up should be individualized according to the
patient’s needs and the degree of response to therapy.
B. Moderate acne
1. Benzoyl peroxide gel (types and dosages as above)
or
2. Retin-A Cream 0.05%
or
3. Differin gel 0.1%

or
4. BenzaClin Topical gel, twice a day
5. Hot soaks to pustules 5 to 6 times a day
6. Tetracycline 250 mg qid or 500 mg bid, over age 12
or alternately
Erythromycin 1 gm/d
7. Recheck in 5 weeks
a. With no improvement and no local irritation:
(1) Increase tetracycline to 1.5 g/d for 2 weeks, then 2 g/d for
2 weeks.
(2) Increase strength of keratolytic gel to 10% or increase
Retin-A to 0.1% cream or change to 0.025% gel.
b. With marked improvement, decrease tetracycline to 250 mg
bid.
8. Recheck again in 4 weeks.
a. With no improvement:
(1) Continue tetracycline at 2 g/d.
(2) Use keratolytic gel at bedtime and Retin-A in the morning.
b. With improvement:
(1) Decrease tetracycline to 250 mg qid or discontinue if
already decreased to bid.
(2) Continue with topical medication.
9. Continue individualized follow-up:
a. Every 4 to 8 weeks while on tetracycline
b. Every 3 to 6 months while on topical medication


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10. Note: If patient is an adolescent female on the birth control pill or
seeking oral contraception order, Ortho Tri-Cyclen #28.
a. It has minimal intrinsic androgenicity.
b. Studies have shown clinically significant improvement in total
acne lesions and inflammatory lesions.
C. Severe or inflammatory acne
1. Topical medication as above
2. Hot soaks to inflamed lesions 5 to 6 times a day
3. Tetracycline 250 mg qid
4. Recheck in 4 weeks. With no improvement, increase tetracycline
as above.
5. Refer to dermatologist if no improvement on this regimen.
D. Note:
1. Limit refills on tetracycline to ensure follow-up visits.
2. Tetracycline is generally drug of choice. It is inexpensive, has few
side effects, and is well-tolerated for long-term administration. The
usual precautions for young children or possibility of pregnancy
should be followed.
3. Antibiotic therapy may take 6 to 8 weeks for any noticeable
improvement to occur.
4. Sulfur can be comedogenic.

5. Keratolytic gels penetrate better than creams or solutions.
6. When discussing acne, do not hesitate to touch the area so child
does not feel he or she is “dirty.” Tell child that blackheads are not
dirt but oxidized melanin.
7. Psychological scarring may occur.
8. Appropriate therapy should be instituted if patient perceives acne
as a problem.
9. “Prom Pills”—Emergency clearing of inflammatory acne for a
prom, wedding, or other major event: Prednisone, 20 mg every
morning for 7 days
10. Do not use BenzaClin gel in conjunction with erythromycin.
VII. Education
A. Acne is chronic. It cannot be cured, but it can be controlled. Acne flare
ups occur in cycles, both hormonal and seasonal.
B. Explain etiology (for psychological support).
C. When local treatment is instituted, acne may appear worse before it
improves. Expect 6–8 weeks before treatment is effective.
D. For mild and moderate acne, the aim is to dry and desquamate the skin.
Expect some dryness, peeling, and faint erythema of the skin.
E. Topical medication
1. If marked erythema and pruritus develop in response to topical
medication, discontinue use temporarily and then resume with less
frequent application.
2. Apply 20 to 30 minutes after gentle washing.
3. Apply lightly to affected area. Do not rub in vigorously.
4. Expect a feeling of warmth and slight stinging with application.


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F. Hygiene
1. Avoid abrasive agents (e.g., over-the-counter scrubs).
2. Shampoo frequently; no special shampoo is necessary.
3. Change pillowcase daily.
4. Do not pick or squeeze lesions; this will retard healing and cause
scarring.
5. Use face cloth and hot water for soaks. Try to soak for 10 to
20 minutes 5 to 6 times a day.
6. Wash face gently three times daily with mild soap; excess scrubbing can exacerbate acne.
7. Facials may exacerbate acne.
8. Use only water-based cosmetics.
a. Oil-free is not necessarily water-based.
b. Use loose powder and blush.
9. Acne medications can be applied under cosmetics and sunscreens.
10. Avoid oily sunscreens. Sundown and PreSun are generally
acceptable.
G. Avoid foods that seem to make acne worse.
H. Overexposure to sunlight can exacerbate acne, alone or in combination
with topical medications. Topical medications can be used under sunscreens. It may, however, be necessary to discontinue these medications
in the summer.

I. Mild sun exposure often dramatically improves acne.
J. High humidity and heavy sweating exacerbate acne, as does exposure
to heavy oils and grease.
K. Tetracycline
1. While on medication, restrict exposure to sunlight.
2. Do not take if there is any question of pregnancy.
3. Take 1 hour before or 2 hours after a meal.
4. If unable to take four times a day because of schedule, take 500 mg
every 12 hours. Nurse practitioner should acknowledge that it
may be a problem for an adolescent to have an empty stomach
4 times a day.
5. Patient must take the full dose for at least 1 month for effective
treatment.
6. Moniliasis may occur in females.
L. Discuss preparations available over the counter. Explain to adolescent
(and parent, if applicable) that it is more cost-effective to follow the
treatment regimen than to try all the latest acne products for the dramatic cures that advertisements promise.
M.Birth control pill may need to be changed to one that does not contain
norgestrel, norethindrone, or norethindrone acetate.
N. T-Stat should be applied with the disposable applicator pads. Drying
and peeling can be controlled by reducing the frequency of application.
O. BenzaClin gel may bleach hair or fabric.
P. Inflammatory acne can result in scarring and/or pigment changes.
Treatment will prevent or minimize these changes.


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VIII. Follow-up
A. Acne is chronic. Treatment should be continued until the process subsides
spontaneously but may be interrupted or discontinued during summer
months when temporary remission may occur because of sun exposure.
B. Return visits need to be individualized according to the severity of the
acne and the emotional needs of the adolescent. Once control has been
achieved, however, the frequency of follow-up can be decreased. The
patient may need to remain on a 250- to 500-mg daily maintenance
dose of tetracycline for several months, in which case 6- to 12-week
return visits should continue. If patient is on topical medications alone,
after acne is controlled, the frequency of application can be adjusted by
the patient, and telephone follow-up may be sufficient.
IX. Complications
A. Psychological problems
B. Secondary bacterial infection
C. Scarring
X. Consultation/referral
A. Moderate acne: Consult for treatment if no improvement noted after treatment with tetracycline for 2 months before continuing treatment plan.
B. Severe or inflammatory acne: Consult for treatment. Refer if no
improvement noted after treatment with tetracycline for 1 month. It
may require more aggressive therapy, such as treatment with Accutane.
C. Severe or resistant acne in a woman if accompanied by hirsutism, irregular menses, or other signs of virilism

A DHD
A neurodevelopment disorder, attention deficit hyperactivity disorder (ADHD) presents as a persistent pattern of inattention, hyperactivity, and impulsivity that is
more frequent and severe than is typically observed in people at a comparable level
of development (Diagnostic and Statistical Manual of Mental Disorders [DSMIV]). There is strong evidence of a genetic component.
Inattention, hyperactivity, and impulsivity—the core symptoms—must be
observed before the age of 7 years and have been present for at least 6 months. Impairment of social, academic or occupational functioning must be evident in more than
one setting. ADHD is diagnosed clinically since no objective tests exist to confirm
the diagnosis.
I. Etiology
Underlying causes unknown but appear to be heterogeneous. Various
environmental factors have been associated with the diagnosis.
Multiple possible etiologies are:
Neuroanatomical/neurochemical
Genetic
Environmental
CNS Insults


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II. Incidence
A. 4%–12% of school children in US according to DSM-IV. Males are at
an increased risk.
B. It frequently co-exists with other conditions. For example, Oppositional
Defiant Disorder is present in 35%, conduct disorder in 26%, anxiety
disorder in 26%, and depressive disorder in 18%.
C. Up to 80% continue symptomatic into adolescence and up to 60% into
adulthood.
D. Siblings of children with ADHD are at greater risk.
III. Types
A. Inattentive
B. Hyperactive/impulsive
C. Combined inattentive/Hyperactive/Impulsive
IV. Subjective findings
A. Inattention:
1. Difficulty paying attention
2. Daydreams
3. Easily distracted
4. Forgetful
5. Careless
6. Disorganized
7. Does not want to do things requiring sustained attention or effort
B. Hyperactivity
1. In constant motion—squirms, fidgets, cannot sit still
2. Talks too much
3. Cannot play quietly
4. Continually “flits” from one activity to another
C. Impulsivity
1. Interrupts conversations and games

2. Cannot wait for turn
3. Answers before question completed
4. Acts without thinking—e.g., runs into street
D. Parents have difficulty with discipline or managing behaviors
E. Poor time management.
F. Room, desk, belongings in a state of chaos.
IV. Objective
A. DSM-IV Criteria for ADHD
1. Inattention: Six or more of the following symptoms of inattention
have been present for at least 6 months to a point that is disruptive
and inappropriate for developmental level:
a. Does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities
b. Often has trouble keeping attention on tasks or play activities
c. Often does not seem to listen when spoken to directly
d. Often does not follow instructions and fails to finish schoolwork, chores or duties in the workplace (not due to oppositional behavior or failure to understand instructions)


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e. Often has trouble organizing activities
f. Often avoids, dislikes, or doesn’t want to do things that take a

lot of mental effort for a long period of time (such as schoolwork or homework)
g. Often loses things needed for tasks and activities (e.g., toys,
school assignments, pencils, books, or tools)
h. Is often easily distracted
i. Is often forgetful in daily activities
2. Hyperactivity-impulsivity: Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least
6 months to an extent that is disruptive and inappropriate for
developmental level:
Hyperactivity

a. Often fidgets with hands or feet or squirms in seat.
b. Often gets up from seat when remaining in seat is expected.
c. Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
d. Often has trouble playing or enjoying leisure activities
quietly.
e. Is often “on the go” or often acts as if “driven by a motor.”
f. Often talks excessively.
Impulsivity

a. Often blurts out answers before questions have been finished
b. Often has trouble waiting one’s turn
c. Often interrupts or intrudes on others (e.g., butts into conversations or games)
d. Some symptoms that cause impairment were present prior to
7 years of age.
e. Some impairment from the symptoms is present in two or more
settings (e.g., at school/work and at home).
f. There must be clear evidence of significant impairment in
social, school, or work functioning.
g. The symptoms do not happen only during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder. The symptoms are not better accounted for by
another mental disorder (e.g., mood disorder, anxiety disorder,

dissociative disorder, or a personality disorder).
V. Assessment
A. Diagnosis:
Assessment is based on the above criteria which is obtained by observation and evaluation of Connors questionnaires from parents and teachers
or by the Vanderbilt rating scale (see Appendix O, p. 572).
There is no single diagnostic test. The diagnosis involves information from several sources and should be made following DSM-IV
criteria.


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1. ADHD, Combined Type: If both criteria from 1. and 2. have been
met for the past 6 months. (Six or more symptoms of inattention
and six or more symptoms of hyperactivity have been present.)
2. ADHD, Inattentive Type: If criterion from 1 has been met for the
past 6 months. (Six or more symptoms of inattention have been
present.)
3. ADHD, Hyperactive-Impulsive Type: If criterion 2 has been met
for the past 6 months. (Six or more symptoms of hyperactivity/
impulsivity have been present.)

B. Rule Out Co-morbid Conditions
1. Oppositional defiant disorder: Loses temper easily, defiant, hostile,
and intentionally annoying; estimated prevalence 35%
2. Anxiety: Fear, worry, panic; estimated prevalence 25%
3. Depressive disorder: Estimated prevalence 18%
4. Conduct Disorder: Estimated prevalence 25%
5. Learning disorders
VI. Treatment
A. Treatment is multifaceted and is predominantly pharmacotherapy
with behavioral interventions, parent training, and school intervention. Dosage of medication should be started low and titrated
upward. Seventy percent of children respond to the first stimulant
prescribed. Approximately half who respond poorly will respond to
second drug prescribed.
B. Stimulants
1. Long-acting stimulants
a. Concerta: 18-, 27-, 36-, or 54-mg extended-release tablets.
(1) 12-hour duration of action
(2) Immediate release at 22%
(3) Dose up to a maximum of 72 mg/d for adolescents
(4) Do not exceed 2 mg/kg/d
b. Focalin XR: 5-, 10-, 15-, or 20-mg extended-release capsules
(1) 12-hour duration of action
(2) Can be sprinkled
(3) Starting dose should be half the currently prescribed dose
of other racemic methylphenidate HCL drugs.
c. Metadate CD: 10-, 20-, 30-, 40-, 50-, or 60-mg extended
release capsules
(1) 8-hour duration
(2) Can be sprinkled
(3) Onset of action 1.5 hours after dosing.

(4) Maximum dose 60 mg/d
d. Ritalin LA: 10-, 20-, 30-, or 40-mg extended-release capsules
(1) 8-hour duration of action
(2) Immediate release at 50%
(3) Useful if increased hyperactivity in AM
(4) Can be sprinkled
(5) Maximum dose 60 mg/d


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2. Intermediate Release Stimulants
a. Adderall: 5-, 7.5-, 10-, 12.5-, 15-, 20-, or 30-mg tablets
(1) First dose on awakening
(2) If needed, give 1 or 2 more doses at 4- to 6-hour intervals.
(3) Maximum dose usually 40 mg/d in 2 or 3 divided doses
b. Adderall XR: 5-, 10-, 15-, 20-, 25-, or 30-mg extended-release
capsules
(1) Give once daily in AM
(2) May be sprinkled
(3) Maximum dose 30 mg/d

c. Dexedrine: 5-mg tablets
(1) Give in AM
(2) Repeat dose every 4–6 hours prn
(3) Maximum dose: 40 mg in 2 or 3 divided doses
(4) May switch to Dexedrine Spansules once titrated
d. Dexedrine Spansules: 5-, 10-, 15-mg sustained-release capsules
(1) Used for once daily dosing once Dexedrine titrated
(2) Maximum dose 40 mg/d
3. Methylphenidate patch (Daytrana): 10-, 15-, 20-, and 30-mg transdermal patch
a. Slow release
b. Useful when child resistant to oral medication
c. Apply daily to alternating hip 2 hours prior to desired effect.
d. Remove after 9 hours. May remove earlier if shorter duration
of effect desired or late day side effects.
e. Titrate at one-week intervals.
C. Non-stimulant
1. Atomoxetine
a. Start with 0.5 mg/d for 3–5 days.
b. Titrate up to 1.2–1.4 mg/kg/d
c. Use if intolerable side effects with stimulants, treatment failure,
or if parents object to stimulant medication.
d. Follow-up on 4–6 weeks.
e. Contraindicated with monoamine oxidase inhibitors (MAOIs).
f. Concurrent use with albuterol, other beta-agonists, and overthe-counter (OTC) cough and cold preparations with pseudoephedrine may cause increases in blood pressure and heart
rate.
D. Monitor academic progress.
1. Maintain contact with school personnel.
E. Monitor social relationships.
F. Monitor height, weight, blood pressure, and pulse on a regular basis.
G. Behavioral Therapy

1. Use in conjunction with medication.
2. Positive reinforcement
3. Time out


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4. Withdraw rewards or privileges for unwanted behavior.
5. Set reasonable goals.
H. Document baseline severity with parents and teachers.
VI. Education
A. Return for height, weight, blood pressure and pulse monitoring as
scheduled.
B. Safety issues
1. Child is apt to be a “risk taker.”
2. Impulsivity and inattention can increase incidence of accidents.
3. Adolescents with ADHD are more prone to motor vehicle accidents.
C. Medication: It may take several trials to adjust the correct medication
and dosage.
D. Atomoxetine

1. May take 3–6 weeks for effect
2. Use if parents object to stimulants
3. Consider use when sleep disturbance and/or significant early
morning hyperactivity are problematic
E. Stimulant medication side effects
1. Decreased appetite
2. Potential for decreased growth
3. Nausea
4. Stomachaches
5. Fatigue
6. Mood swings
7. Tics
8. Stuttering
F. Administer medication with or after a meal.
G. Beads from sprinkled capsules should not be chewed.
H. Without treatment, child at-risk for
1. Disorganization in school work
2. Poor self-esteem
3. Risky behavior
4. Poor peer relationships
5. Increased incidence of depression, anxiety, and/or substance abuse.
I. Reassure parents that it is not “their fault.”
J. Maintain firm, consistent limits: Present a “united front.”
K. Reward positive behaviors.
L. Adhere to a daily routine. Advise child prior to change in routine.
M.Provide quiet place with minimal distractions for homework.
N. Behavioral therapy assists child in learning about responsibility and
control over his or her behavior.
O. Anticipate problem settings: Make a plan, review rules, and establish
incentive.

P. Make commands effective. State, don’t ask and go to child and maintain
eye contact.
Q. Do not give multiple tasks and if task complex, divide into small steps.


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R.
S.
T.
U.

Time outs for infractions should be limited in length.
ADHD generally continues into adulthood.
Recognize that a child with ADHD creates stress for parents.
Maintain open communication with schools. Discuss implementation of
accommodations with teacher and administration. Daily behavior charts
are effective as well.
V. Additional services can be obtained, if appropriate, through
1. IDEA (Individuals with Disabilities Education Improvement Act)
2. Section 504 (Rehabilitation Act of 1973)

3. ADA (Americans with Disabilities Act of 1990)
4. ESEA-NCLB 2001 (the Elementary and Secondary Education Act)
5. However, in itself, ADHD is not considered a learning disability.
W.Treatment for ADHD is long-term and will require ongoing communication and planning with child’s doctor, teacher, and others involved
with the child.
VII. Follow-up
A. Telephone call every one to two weeks to check on medication response.
B. Recheck in office monthly until medication is adjusted and satisfactory
progress is seen.
C. Further follow-up visits according to need based on school and social
progress and expected outcomes.
D. Parent will need to come to office every month to get prescription for
medication.
VIII. Consultation/referral
A. Children with cardiovascular abnormalities
B. Children under 7 years of age
C. Children with co-morbid conditions

Resources/Suggested Readings
BOOKS
American Academy of Pediatrics. (2004). ADHD: A complete and authoritative guide. Elk
Grove Village, IL: Author.
Ashley, S. (2005). ADD and ADHD answer book. Naperville, IL: Sourcebooks, Inc.
Barkley, R. A. (2000). Information and guidance for parents in the management of children
with ADHD. Taking Charge of ADHD: The Complete Authoritative Guide for Parents.
New York: Guilford Publications.
Gordon, M. (1991). Jumpin’ Johnny get back to work! A child’s guide to ADHD/Hyperactivity.
Ages 5–10. DeWitt, NY: GSI Publications.
Hallowell, E., & Ratey, J. (2005). Delivered from distraction: Getting the most out of life with
attention deficit disorder. New York: Random House Publishing Group.

Reif, S. F. (2005). How to reach and teach children with ADD/ADHD: Practical techniques,
strategies, and interventions. Hoboken: NJ: John Wiley & Sons.

WEBSITES
National Institute of Mental Health. Telephone: 301-443-4513. Website: h.
nih.gov


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National Attention Deficit Disorder Association. Telephone: 847-ADHD-377. Website:

Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). Telephone:
800-233-4050. Website:

ALLERGIC RESPONSE

TO

HYMENOPTERA

A local or systemic reaction to the sting of an insect, generally a bee, wasp, or
hornet.
I. Etiology
A. Hypersensitivity is an IgE-mediated response. Generally an initial
exposure is followed by re-exposure, and the re-challenge elicits the
reaction.
B. Hymenoptera
1. Bee family: Bees and honey bees
2. Wasp family: Yellow jackets, wasps, and hornets
3. Ant family: Fire ants of southeastern United States (attack en masse)
II. Incidence
A. 90% of children experience a normal reaction of less than 2 inches in
diameter and less than 24 hours in duration.
B. 10% of children will have a large local reaction greater than 2 inches in
diameter and lasting up to 7 days.
C. Anaphylaxis occurs in 0.4% to 0.8% of the general population.
D. Approximately 50 deaths from stings occur in the United States
every year. The sting of a bee, wasp, or yellow jacket is more apt to
produce severe, immediate hypersensitivity reactions than any other
insect.
III. Subjective data
A. History of bite or sting
B. Local reaction
1. Swelling and redness at site of sting
2. Intense local pain
C. Systemic reaction; may be a combination of the following:
1. Anxiety, initially
2. Nausea
3. Itching

4. Sneezing, coughing
5. Hives or frank angioedema, with various parts of skin swollen
6. Swelling of lips and throat
7. Difficulty swallowing
8. Difficulty breathing
9. Stridor
10. Respiratory compromise with ultimate collapse
11. Vertigo


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IV. Objective data
A. Local reaction
1. Local wheal and flare reaction with central punctum
2. Edema around sting site
3. Normal reaction
a. Swelling less than 2 inches in diameter
b. Duration less than 24 hours
4. Large local reaction

a. Edema more than 2 inches in diameter
b. Duration 1 to 7 days
B. Systemic reaction: Signs of anaphylaxis; generally occur within
30 minutes
1. Anxiety
2. Urticaria
3. Dysphagia
4. Laryngeal edema
5. Bronchospasm
6. Dyspnea
7. Cyanosis
8. Drop in blood pressure and pulse
9. Voice changes
V. Assessment
A. Hymenoptera sting by history (honey bee, if the stinger is left intact)
B. Differential diagnosis of anaphylaxis
1. Vasopressor syncope: Self-limited, no pulmonary involvement,
rarely occurs when child is prone, blood pressure and pulse do not
drop, child rouses after breathing amyl nitrite
2. Cardiac failure
3. Anxiety attack
4. Penicillin allergy
5. Obstruction in laryngotracheobronchial tree
6. Aspiration of foreign body
VI. Plan
A. Normal local reaction
1. Remove stinger by scraping off. The protruding end contains the
venom sac, and pinching or using forceps will cause more venom
to be pumped into the wound.
2. Topical application of ice

3. Benadryl, 1 mg/kg, up to 50 mg
4. Calamine lotion
B. Large local reaction or multiple stings
1. Local measures as above
2. Prednisone, 1 mg/kg/d for 5 days may be helpful
C. Systemic reaction
1. Apply tourniquet proximal to sting on an extremity.
2. Remove stinger; shave off stinger of honey bee (has reverse
serrations).


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TABLE 2–1 Epinephrine 1:1000 Dosage Table
K ILOS
10
15
20
25
30 and over

P OUNDS

D OSAGE ( M L)

22
33
44
55
66

0.1
0.15
0.2
0.25
0.3

3. Administer epinephrine 1:1000, 0.01 mL/kg SC (maximum
0.3 mL); rub. Repeat in 15 to 30 minutes (see Table 2-1)
4. Benadryl, 1 mg/kg, up to 50 mg
a. Antihistamines should be used as an adjunct to epinephrine to
block the effects of histamine on the receptor sites.
b. Antihistamines do not prevent bronchoconstriction; their greatest
benefit is in blocking reaction of mucous membrane and skin.
5. Transport patient immediately to emergency room.
6. Refer patient to allergist for testing and possible immunotherapy.
7. Order EpiPen, and instruct patient or parent in its use.
a. EpiPen for patients 30 kg and over
b. EpiPen Jr. for patients 15 kg and over
c. Use trainer pen for instruction

8. Order rapid-acting antihistamine: Zyrtec (syrup 1 mg/mL, chewables
5 mg and 10 mg, tablets 5 mg and 10 mg)
a. 0.25 mg/kg: less than 2 years of age
b. 2.5–5 mg: 2–6 years of age
c. 5–10 mg: More than 6 years of age
VII. Education
A. Do not wear perfumes, hair spray, aftershave, and so forth when outside.
B. Wear neutral colors; flowery prints are apt to attract bees.
C. Do not walk barefoot outside. Yellow jackets, the most aggressive
hymenoptera, nest in the ground.
D. Avoid flower beds, playgrounds, picnic areas, and trash or garbage
disposal areas.
E. No insect repellent is available that repels stinging insects.
F. Do not run or engage in physical activity after a sting.
G. The honey bee stinger has reverse serrations and leaves its stinger in the
skin with the venom sac attached to it. The venom sac continues to eject
venom and will empty out completely if compressed. Do not squeeze it;
instead, scrape or shave the stinger off.
H. Wasps and yellow jackets retain their stingers and may sting repeatedly.
I. 70% of deaths due to hymenoptera are caused by airway edema or
respiratory compromise.


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J. 85% of children who go into anaphylactic shock do so within the first
15 to 30 minutes of exposure.
K. Anaphylaxis has occurred as late as 6 hours following exposure, but
this is highly unusual.
L. Steroids do not help against the initial insult but will help against a
delayed recurrence after the initial treatment.
M.Skin testing for allergy may yield a false-negative result if done too
soon after treatment for a sting; wait 3 to 4 weeks after a sting before
doing such testing.
N. Immunotherapy reduces risk of life-threatening complications from
60% to less than 5%.
O. EpiPen spring-loaded syringe contains epinephrine in a premeasured
dose. EpiPen delivers 0.30 mg (in patients >30 kg) and EpiPen Jr.
delivers 0.15 mg (in patients >15 kg) of epinephrine.
P. Administer EpiPen into anterolateral aspect of thigh—through clothing
if necessary.
Q. Parents should notify school, day care, camp, and other caretakers of
reaction and have EpiPen available for child at all times.
R. Child should wear a MEDIC ALERT bracelet.
VIII. Follow-up
A. Contact after discharge from hospital to ensure that parent or child has
made appointment with allergist for testing.
IX. Complications
A. Anaphylaxis following rechallenge
B. Delayed systemic reaction

X. Consultation/referral
A. Refer any patient who has had an immediate systemic reaction to allergist.
B. Consult with allergist on any patient who has had a large local reaction.

ALLERGIC RHINITIS

AND

CONJUNCTIVITIS

An allergic response resulting in inflammation of the mucous membrane. It is characterized by chronic, thin, watery nasal discharge with or without concurrent conjunctival discharge, inflammation, and pruritus.
I. Etiology
A. IgE-mediated immunologic reaction to common inhaled allergens (pollens, molds, dust, animal dander). The mediators cause increased permeability of the mucosa and produce vasodilation, mucosal edema,
mucous secretions, stimulation of the itch receptors, and a reduction in
the sneezing threshold.
B. Seasonal allergic rhinitis is generally caused by non-flowering, windpollinated plants, and fungal spores.
Allergens vary seasonally and by geographic distribution and
commonly include tree pollens in the early spring, grasses in late spring


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and early summer, and weeds primarily in the fall. However, in many
areas, various weeds pollinate from spring through fall.
C. Perennial allergic rhinitis is caused by allergens that are present year
round such as animal dander, dust, cockroaches, and molds.
D. Food allergens are not a common cause of allergic rhinitis.
II. Incidence
A. Allergic rhinitis is the most common atopic disease and the most common chronic disease in children.
B. Usually seen after 3 to 4 years of age but can develop at any age
C. Affects approximately 10% of the population
D. 80% to 90% percent of children with asthma have concomitant allergic
rhinitis.
III. Subjective data
A. Nasal stuffiness: Varies from mild to chronic obstruction
B. Rhinorrhea: Bilateral, thin, watery discharge
C. Paroxysms of sneezing
D. Itching of nose, eyes, palate, pharynx
E. Conjunctival discharge and inflammation
F. Mouth breathing
G. Snoring
H. Fatigue, irritability, anorexia may be present during season of offending
allergen.
I. Allergic salute: Rubbing the tip of the nose upward with the palm of the
hand
J. Recurrent nosebleeds
K. Persistent, nonproductive cough
L. Pertinent subjective data to obtain
1. History of associated allergic symptoms: Asthma, urticaria, contact dermatitis, eczema, food or drug allergies
2. Family history of allergy

3. Does child always seem to have a cold, or does it occur at specific
times of the year (perennial versus seasonal)?
4. Are symptoms worse in any particular season?
5. Do parents or child notice that symptoms are worse after exposure
to specific allergens, such as animals, wool, feathers, or going into
attic or cellar?
6. Are symptoms worse when child is indoors or outside?
7. What do parents or child think causes symptoms?
8. Can child clear nose by blowing?
9. What makes child feel better?
10. How much do symptoms bother child and family?
IV. Objective data
A. Allergic shiners: Bluish cast under eyes
B. Allergic crease: Transverse nasal crease at junction of lower and middle
thirds of nose
C. Clear mucoid nasal discharge
D. Pale edematous nasal mucosa


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E. Nasal turbinates swollen and may appear bluish
F. Nasal phonation
G. Mouth breathing
H. Conjunctivae may be inflamed. “Cobblestoning” of upper lids may be
present.
I. Tearing
J. Edema of lids
K. Laboratory test: Nasal smear positive for eosinophilia
V. Assessment
A. Diagnosis
1. Differentiate between the following:
a. Seasonal allergic rhinitis occurs seasonally as a result of exposure to airborne pollens: generally tree pollens in late winter
and early spring, grass pollens in spring and early summer, and
weeds in late summer and early fall.
b. Perennial allergic rhinitis occurs all year but is usually worse in
winter due to increased exposure to house dusts from heating
systems, pets, wool clothing, and other allergens.
2. Classify as:
a. Mild: No sleep interruption, no interference with activities, no
troublesome symptoms
b. Moderate–severe: Involves sleep interruption and/or impairment of daily activities, troublesome symptoms
c. Intermittent: Symptoms less than 4 days/week or duration
under 4 weeks
d. Persistent: Symptoms over 4 days/week or duration more than
4 weeks
B. Differential diagnosis
1. Infectious rhinitis or recurrent colds: Nasal discharge watery to
thick yellow, low-grade fever, symptoms develop after exposure
to cold virus, 5 to 7 days duration.

2. Foreign body: Unilateral purulent nasal discharge with foul odor
3. Vasomotor rhinitis: Symptoms precipitated by exposure to temperature changes or specific irritants (smoke, air pollutants, strong
perfume, chemicals); symptoms appear suddenly and disappear
suddenly.
4. Rhinitis medicamentosus: History of chronic use of nose drops
5. Acute or chronic sinusitis: Nasal mucosa is usually inflamed and
edematous; discharge is generally mucopurulent; may have lowgrade fever.
6. Cystic fibrosis: Consult if nasal polyps are present.
VI. Plan: Involve child in treatment plan as much as developmental level
allows.
A. Pharmacologic therapy
1. Antihistamines relieve rhinorrhea, sneezing, and itching.
2. Decongestants improve nasal congestion.


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3. Intranasal steroids suppress the entire inflammatory process in the
nose but do little for relief of ocular symptoms or systemic
manifestations.

4. Optimal results may be obtained with a combination of nasal cromolyn or steroids and an antihistamine or decongestant.
5. Antihistamines for seasonal rhinitis
a. Ages 6 to 12 years
(1) Benadryl, 5 mg/kg/d in four divided doses (>10 kg,
12.5–25 mg tid–qid)
(2) Tavist syrup, 0.5 mg/5 mL: 1 tsp every 12 hours
(3) Zyrtec syrup, 5 mg/5 mL: 1 to 2 tsp daily depending on
severity of symptoms
(4) Allegra suspension (recently FDA-approved for ages
2–11 years): 15 mg bid
b. Ages 12 and over
(1) Claritin, 10 mg/d
(2) Zyrtec, 5 to 10 mg once daily, depending on severity of
symptoms
6. Decongestant-antihistamine combination
a. Pseudoephedrine (Actifed, Sudafed): 2–6 years, 5 mL qid;
6–12 years, 10 mL qid
b. Rondec: 2–6 years, 1.25 mL every 4–6 hours, max 7.5 mL/d
6 –12 years: 2.5 mL every 4–6 hours, max 15 mL/d
More than 12 years: 5 mL every 4–6 hours, max 30 mL/d
7. Intranasal corticosteroids: Believed by many experts to be the
most effective pharmacologic therapy for allergic rhinitis.
a. Vancenase AQ: 1–2 sprays each nostril once daily for children
over 6 years of age
or
b. Nasacort AQ: 2 sprays in each nostril once daily for children
over 12 years of age, 1 spray each nostril once daily for children ages 6 to 12 years
or
c. Rhinocort Aerosol: 1–2 sprays each nostril q 12 hours for children over 6 years of age. May increase to 2 sprays each nostril
once daily. Over 12 years, maximum 4 sprays each nostril

once daily.
or
d. Flonase, one spray in each nostril once daily for children over
4 years of age; may increase to 2 sprays once daily
8. Ophthalmic preparations:
a. Patanol ophthalmic: 1 gtt in each eye twice daily at 6- to 8-hour
intervals for children over 3 years of age; indicated for all signs
and symptoms, including itching, erythema, lid edema, and
tearing
or


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b. Alocril ophthalmic: 1 to 2 drops in each eye, every 12 hours for
children over 3 years of age
or
c. Alomide ophthalmic: 1 to 2 drops in each eye, qid for up to
3 months, for children over 2 years of age
or

d. Optivar ophthalmic: 1 drop in each eye, bid for children more
than 3 years of age
B. Avoidance: Identify and avoid offending allergens (see Environmental
Control for the Atopic Child, p. 291).
1. Seasonal allergic rhinitis: Ragweed, trees, grasses, molds
2. Perennial: House dust, feathers, animal dander, wool clothing or
rugs, mold
3. Environmental stimuli: Cold air, paint fumes, smoke, perfumes
C. Desensitization: Referral, indicated if
1. symptoms are severe and cannot be controlled with symptomatic
therapy.
2. recurrent serous otitis occurs with resultant hearing loss.
3. symptoms become progressively worse or asthma develops.
4. allergen avoidance is impossible.
VII. Education
A. Advise parents that this is a chronic problem, although symptoms may
sometimes decrease with age and then disappear. Exacerbation of
symptoms may occur, particularly as child approaches puberty.
B. Discuss indications for hyposensitization.
1. Inability to suppress symptoms with conservative treatment
2. Inability to avoid allergens
3. Severe symptoms affecting child’s normal lifestyle (school, sleep,
play)
4. 30% to 50% of children with allergic rhinitis who are not treated
develop asthma
5. Desensitization is a lifelong process.
C. Discuss specific allergen control (see Environmental Control for the
Atopic Child, p. 291).
D. Advise child and parents of possible hearing loss due to serous otitis.
E. Notify school of child with hearing loss.

F. Inadequate symptom control may contribute to learning impairment.
G. Side effects of antihistamines.
1. Sedation (often resolves with continued use); nightmares
2. Excitation, nervousness, tachycardia, palpitations, irritability
3. Dryness of mouth
4. Constipation
H. Antihistamines relieve nasal congestion, itching, sneezing, and rhinorrhea. Continuous therapy is more efficacious than sporadic use.
I. Topical anti-allergic ophthalmics also have a positive effect on nasal
symptoms by draining into inferior nasal turbinates.


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J. Intranasal corticosteroids
1. Reduces nasal stuffiness, discharge, and sneezing
2. Maximum benefit achieved in 1 week
K. Child should not wear soft contact lenses when using ophthalmic drops.
L. Ophthalmic preparations may cause transient stinging or burning.
M.Child with allergic rhinitis is more prone to upper respiratory and ear
infections.

N. Child cannot clear nose by blowing it.
O. Child may not be able to chew with his or her mouth closed.
P. Epistaxis may be a problem because of nose picking and rubbing. Control nosebleed by compressing lower third of nose (external pressure
over Kiesselbach’s triangle) between fingers for 10 minutes.
VIII. Follow-up
A. Return visit or telephone follow-up in 2 weeks for reevaluation. Contact
sooner if adverse reaction to medication occurs.
B. If no response to medication, increase dosage to control symptoms.
Reevaluate in 2 weeks. Change type of antihistamine if indicated.
C. If symptoms under control, continue medication until suspected allergen
no longer a threat. Medication may then be used as needed to control
symptoms.
D. Return visit at any time that child or parent feels symptoms are worse
or medication has ceased to control symptoms.
IX. Complications
A. Bacterial infection
B. Recurrent serous otitis media
C. Malocclusion
D. Psychosocial problems
X. Consultation/referral
A. Symptoms have not abated after a trial period of 4 weeks on antihistamines.
B. Parent or child sees symptoms as a major problem and requests skin
testing.
C. Recurrent serous otitis affecting hearing or school progress

ANOREXIA NERVOSA
A symptom complex of nonorganic cause resulting in extreme weight loss in the
preadolescent or adolescent
I. Etiology
A. Anorexia nervosa is generally hypothesized to be due to reactivation at

puberty of the separation-individuation issue: the adolescent’s attempt
to maintain or initiate a sense of autonomy and separateness from the
mother.
B. Starvation gives the adolescent a sense of identity and control over
what is happening to one’s body.


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II. Incidence
A. Affects approximately 5% of women ages 15–30.
B. 90% to 95% of anorexics are female, with the peak onset occurring at
ages 14 and 18 years.
C. Most cases are from middle to upper socioeconomic families but can be
of any race, gender, age, or social stratum. Patients are commonly
members of the same family.
D. Generally seen in perfectionists or “model children” with poor selfimages. They are high achievers academically and are frequently
engaged in strenuous physical activity, such as varsity sports or vigorous exercise programs. Parents are often overprotective, controlling,
and demanding. Children feel unable to live up to parental expectations
despite strict adherence to these expectations.

E. In terms of body weight, 80% of anorexics respond to therapy, although
other psychosocial problems may be prolonged. Amenorrhea persists in
13% to 50% even after weight returns to normal or is stabilized at 85%
to 90% of ideal weight.
F. Mortality from physiologic complications or suicide is approximately
6%.
III. Subjective data
A. Weight loss
B. Amenorrhea: Absence of three consecutive menstrual periods
C. Constipation
D. Abdominal pain
E. Cold intolerance
F. Fatigue
G. Insomnia
H. Depression, loneliness
I. Dry skin and hair
J. Headaches (“hunger headaches”)
K. Fainting or dizziness
L. Anorexia
M.Pertinent subjective data to obtain
1. Preoccupation with food and dieting
a. History of dieting
b. Denial of hunger
c. Patient finds food revolting but may spend time preparing
gourmet meals for others.
d. History of food rituals
2. Morbid fear of gaining weight
3. Weight history: Highest and lowest weights achieved
4. Vomiting after meals
5. Low self-esteem, poor body-image; patient complains of being fat,

when in reality, one is not.
6. Dietary history
7. Menstrual history


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Anorexia Nervosa
8.
9.
10.
11.
12.
13.
14.

225

Perceived body image
History of impulsive behaviors: Stealing, self-mutilation
History of suicide gestures
Excessive exercising
Laxatives, diuretics, or other medications used to control weight
Recent family or social stress

History of unpleasant sexual encounter; patient may be using starvation to try to halt development of secondary sex characteristics.
15. History of sexual activity; condition may be unconscious attempt
to abort a pregnancy.
16. History of drug or alcohol abuse
N. Note: Anorexia nervosa may be identified in its early stages by a conscientious health care provider eliciting a history during a routine health
maintenance visit. Any combination of the above should create a high
index of suspicion.
IV. Objective data
A. Weight loss: More than 15% below ideal body weight (IBW) or in
prepubertal patients, failure to gain height and weight
B. Emaciation: Patient appears gaunt, skeletal.
C. Bradycardia
D. Orthostatic hypotension
E. Hypothermia
F. Skin: Dry and flaky, lanugo hair, loss of subcutaneous fat, jaundice
G. Hair loss: Scalp and genital area
H. Extremities: Edema, cyanosis, mottling, cold; slow capillary refill in
hands and feet
I. Compulsive mannerisms (e.g., handwashing)
J. Apathy, listlessness
K. Loss of muscle mass
L. Occasionally, scratches on palate from self-induced vomiting
M.Laboratory findings
1. Usually normal until later stages of malnutrition
a. CBC: Anemia
b. UA: Monitor SG (patients may water load prior to being
weighed)
2. If experiencing amenorrhea
a. HCG to rule out pregnancy
b. TFT, prolactin, FSH

3. With malnutrition
a. Leukopenia: Characteristic of starvation
b. Lymphocytosis
c. Low sedimentation rate
d. Low fibrinogen levels
e. Low serum lactic dehydrogenase estrogens
f. Low T3
g. Electrolyte imbalance if vomiting: MG, Ca, Phos